Continuous monitoring of prostate position using stereoscopic and monoscopic kV image guidance

Purpose: To demonstrate continuous kV x-ray monitoring of prostate motion using both stereoscopic and monoscopic localizations, assess the spatial accuracy of these techniques, and evaluate the dose delivered from the added image guidance. Methods: The authors implemented both stereoscopic and monoscopic fiducial localizations using a room-mounted dual oblique x-ray system. Recently developed monoscopic 3D position estimation techniques potentially overcome the issue of treatment head interference with stereoscopic imaging at certain gantry angles. To demonstrate continuous position monitoring, a gold fiducial marker was placed in an anthropomorphic phantom and placed on the Linac couch. The couch was used as a programmable translation stage. The couch was programmed with a series of patient prostate motion trajectories exemplifying five distinct categories: stable prostate, slow drift, persistent excursion, transient excursion, and high frequency excursions. The phantom and fiducial were imaged using 140 kVp, 0.63 mAs per image at 1 Hz for a 60 s monitoring period. Both stereoscopic and monoscopic 3D localization accuracies were assessed by comparison to the ground-truth obtained from the Linac log file. Imaging dose was also assessed, using optically stimulated luminescence dosimeter inserts in the phantom. Results: Stereoscopic localization accuracy varied between 0.13±0.05 and 0.33±0.30 mm, depending on the motion trajectory. Monoscopic localization accuracy varied from 0.2±0.1 to 1.1±0.7 mm. The largest localization errors were typically observed in the left-right direction. There were significant differences in accuracy between the two monoscopic views, but which view was better varied from trajectory to trajectory. The imaging dose was measured to be between 2 and 15 μGy/mAs, depending on location in the phantom. Conclusions: The authors have demonstrated the first use of monoscopic localization for a roommounted dual x-ray system. Three-dimensional position estimation from monoscopic imaging permits continuous, uninterrupted intrafraction motion monitoring even in the presence of gantry rotation, which may block kV sources or imagers. This potentially allows for more accurate treatment delivery, by ensuring that the prostate does not deviate substantially from the initial setup position.